INCREASING ACCESS TO FAMILY PLANNING AMONG INDIGENOUS GROUPS IN GUATEMALA DECEMBER 2008 This publication was produced for review by the U.S. Agency for International Development (USAID). It was prepared by Sara Netzer and Liz Mallas of the Health Policy Initiative, Task Order 1. The USAID | Health Policy Initiative, Task Order 1, is funded by the U.S. Agency for International Development under Contract No. GPO-I-01-05-00040-00, beginning September 30, 2005. Task Order 1 is implemented by Futures Group International, in collaboration with the Centre for Development and Population Activities (CEDPA), White Ribbon Alliance for Safe Motherhood (WRA), Futures Institute, and Religions for Peace. INCREASING ACCESS TO FAMILY PLANNING AMONG INDIGENOUS GROUPS IN GUATEMALA DECEMBER 2008 The views expressed in this publication do not necessarily reflect the views of the U.S. Agency for International Development or the U.S. Government. CONTENTS Acknowledgments ......................................................................................................................................iv Executive Summary ....................................................................................................................................v Abbreviations ............................................................................................................................................vii I. Introduction.......................................................................................................................................1 II. Background Analysis ........................................................................................................................1 Poverty Among Indigenous People.....................................................................................................1 Policy Environment.............................................................................................................................1 Market .................................................................................................................................................3 Supply...............................................................................................................................................3 Demand............................................................................................................................................3 Finance................................................................................................................................................4 III. Information Gathering and Analysis...............................................................................................5 Barriers to Service Delivery................................................................................................................7 1. Provider bias toward indigenous women.....................................................................................7 2. Unsuitable conditions in facilities providing FP/RH services.....................................................8 3. Lack of appropriate information, education, and communication materials ..............................9 4. Limited integration of community-based providers in the community.........................................9 Socio-Cultural Barriers .....................................................................................................................10 5. Community beliefs regarding FP/RH ........................................................................................10 6. Restrictive social and familial environments.............................................................................10 IV. Policy Dialogue and Strategy Development ..................................................................................10 V. Implementation ...............................................................................................................................12 VI. Policy-Related Outcomes................................................................................................................15 VII. Lessons Learned and Best Practices..............................................................................................16 VIII. Conclusion........................................................................................................................................18 References..................................................................................................................................................19 Other Resources........................................................................................................................................19 iii ACKNOWLEDGMENTS This report is a review of the work led by Varuni Dayaratna, Jay Gribble, Marisela de la Cruz, and Lucia Merino in partnership with the Ministry of Public Health and Social Welfare, Guatemalan Institute for Social Security, and Association for the Wellbeing of the Family. The Guatemalan Association of Women Doctors, Guatemalan Association of Gynecologists and Obstetricians, USAID/Guatemala, United Nations Population Fund, and Population Council/Guatemala also contributed to the analysis and discussion of the study results. The authors would like to acknowledge Dr. Anabella Pérez and Thelma Suchi, who served as local coordinators; Claudia Quinto and Eugenia Monroy, who conducted the provider interviews; Lucrecia Cumes and Sandra Ixjotop de Rucal, who conducted the group interviews; and Claudia Quinto, who did the data analysis. The authors would also like to thank Suneeta Sharma, Lucia Merino, and Cynthia Green of the Health Policy Initiative for their valuable comments and editorial contributions. The paper titled Increasing Access to Family Planning Among the Poor in Peru by Elaine Menotti, Suneeta Sharma, and Gracia Subiria provided valuable input for this report. Mai Hijazi, Diana Prieto, and Shelley Snyder at the United States Agency for International Development ably guide the work of the Health Policy Initiative. Their technical direction in support of this report is much appreciated. iv EXECUTIVE SUMMARY This report describes an initiative to promote equitable access to family planning and reproductive health services (FP/RH) among indigenous women in Guatemala. The lessons learned from this approach and its application in five districts can be applied to other settings. In Guatemala, the USAID | Health Policy Initiative, Task Order 1, has worked to foster an enabling environment for the implementation of adequately financed, effective, sustainable, and culturally appropriate FP/RH programs. To achieve this, the project has focused on supporting indigenous leadership, policy dialogue, and advocacy (building on previous work by its predecessor, the POLICY Project). In partnership with the Ministry of Public Health and Social Welfare (MSPAS), the Guatemalan Institute for Social Security (IGSS), and the Association for the Wellbeing of the Family (APROFAM), the Health Policy Initiative (1) collected and analyzed information related to access to services and unmet need for FP among indigenous groups; (2) discussed the findings with key stakeholders and supported policy dialogue to identify strategies and service delivery practices to address the issues identified; (3) tested the strategies and practices; (4) conducted follow-up interviews with program implementers; and (5) identified lessons learned that can guide future work to make FP/RH services more accessible to disadvantaged groups. This report discusses the background and rationale for this work, reviews efforts to reach the underserved, and describes the process of identifying barriers and implementing the recommended strategies. The final section provides lessons learned and recommended actions for other countries to reduce barriers to access and use of FP/RH services among poor and marginalized groups. To better conceptualize the policy framework, the project reviewed existing research and policies to identify the factors affecting access to FP/RH services. The project then conducted 108 in-depth interviews with service providers, 22 group interviews with 168 indigenous women, and 11 group interviews with 69 community educators and traditional midwives in three departments (Quiché, Sololá, and Totonicapán) of Guatemala. Based on the research findings, the project identified six major barriers that limit access to FP/RH services among indigenous groups: 1. Provider bias toward indigenous women 2. Unsuitable conditions in facilities providing FP services 3. Lack of appropriate information, education, and communication materials 4. Limited integration of community-based providers in the community 5. Community beliefs regarding family planning 6. Restrictive social and familial environments During stakeholder workshops at the national and community levels, project staff presented these findings; and participants from the MSPAS, IGSS, and APROFAM, as well as civil society organizations, developed a set of service delivery practices that could improve access to services. These practices were then incorporated into operational guidelines that were pilot-tested in five districts in Quiché. The districts were selected because of their high maternal mortality ratios and low contraceptive prevalence. The Health Policy Initiative helped the Departmental Office of Health in Quiché develop a list of 10 locally appropriate service delivery practices. These practices involved providing services